Insurance Coverage and Weight loss Surgery

The surgical treatment of morbid obesity is a covered benefit under many insurance policies. Coverage depends on what type of policy you have and the terms within the policy. Each insurance policy can vary greatly, even if different policies are issued by the same insurance company.  Your employer and the insurance company determine the benefits available to you.

Will my insurance pay for my surgery?

Once your surgeon has determined that surgery is medically necessary, we must seek approval in writing from your insurance company.   More than likely, we will know in advance what your insurance company will require but there are occasions where the insurance company will send us a list of requirements which are customized to your policy.  You may be able to check on-line, the policy bulletin for your particular company.  Please keep in mind that not all insurance companies require a lot of documentation and that we will help you through the process. 

Your insurance company may ask for some of the following items before authorizing your surgery:

• A detailed diet history

• Current height, weight and BMI (body mass index)

• A list of all co-morbidities that are or may be caused by your morbid obesity

• A psychological evaluation/clearance

• A thorough medical history

• Internal Medicine Clearance

• A recent medically supervised diet history

• Medical records documenting your history of morbid obesity

• Certain medical tests

What if my insurance company denies my request?

If your insurance company denied coverage for surgery, don't give up hope. In many cases, providing additional information in the form of an appeal letter could result in your denial being overturned. If your insurance carrier continues to deny coverage, you may consider seeking legal assistance.   We have an appeals expert on our staff.

What is an “Exclusion?”

Unfortunately, many policies have “Exclusions” written into them.  This means that even though the treatment may be “Medically Necessary”, it is not a covered benefit.   Industry leaders are working diligently to make national changes regarding coverage and Medicare’s announcement of national coverage may help the push for all insurance companies to provide coverage.   If your policy has an “Exclusion”, there is little that can be done.  There are some options you may want to evaluate:

*You may have to change policies, if this is an option, during open enrollment from the HMO to the PPO, although there is no guarantee that the other policy will cover obesity surgery.

*You may have to change to a spouse’s policy.

*You may have to finance or privately pay the surgery (please call our office for details).